What's Ahead for EHRs: Experts Weigh In


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Industry experts from health care and informatics ponder the future of electronic health records during the implementation of "meaningful use" and beyond.

Read more: http://www.chcf.org/publications/2012/02/whats-ahead-ehrs#ixzz1mTJUcSev

Republished with permission from the California HealthCare Foundation

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What's Ahead for EHRs: Experts Weigh In

  1. 1. What’s Ahead for EHRs:Experts Weigh InIntroductionTechnology broke new ground in 1982: The Meaningful Use of EHRs The Meaningful Use Incentive Programfirst artificial heart was implanted in a human, establishes criteria for evaluating whether EHRsSony released the first compact disc player, and improve health care quality, creates incentivesthe Commodore 64 took the computer world by for widespread implementation, and outlines a Issue BrIefstorm. framework for measuring how EHRs are used. The program is part of the Health InformationThat same year, Mark Leavitt, MD, PhD, retired Technology for Economic and Clinical Healthchair of the Certification Commission for Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009. TheInformation Technology, began writing software meaningful use program is intended to unfold inon an Apple II Plus to automate patient records in three stages with escalating requirements overhis internal medicine practice. He was among the five years. Stage 1 regulations were released inearly adopters of electronic health records (EHRs), July 2010.which allowed for the input of progress notes, A year later, more than 90,000 eligibleproblems lists and medications, laboratory data, professionals and hospitals had enrolled in the EHR incentive program, and more thanand physician orders. Over the following decades, $650 million in payments had been distributedEHR platforms have moved from stand-alone by the Centers for Medicare and Medicaidterminals to mobile devices and tablets, but their Services (CMS). The number of physiciansbasic functionality has evolved little since those who reported having a basic system increased 36% since 2010, and has nearly doubled sinceearly days. 2008 (rising from 17% to 34%).1 Criteria for a basic system include patient history andNevertheless, provider adoption of EHRs is demographics, patient problem list, physicianincreasing quickly, spurred in part by the federal clinical notes, comprehensive list of patient’sMeaningful Use Incentive Program, enacted in medications and allergies, computerized orders for prescriptions, and ability to view laboratory2009 to encourage “meaningful use” of health results electronically.information technology by professionals andhospitals (see sidebar). With widespread adoption,many believe that EHRs could potentially enablevast improvements in health care quality by To gain insight on the future EHR landscape andincreasing workflow efficiencies and patient safety; the role of meaningful use, Booz Allen Hamiltonoffering medical providers complete, accurate, and conducted interviews with industry experts acrosstimely information; and empowering patients to the health care and informatics communities.be more active participants in their own health. It (See Appendix A for a list of interviewees.)is less clear to what extent EHRs are on track tomeet these expectations and what barriers might Overall, the interviews revealed that meaningfulstand in the way. use has spurred adoption of EHRs across the F ebruary 2012
  2. 2. provider community, but that there have been unintended EHR Roots in Codingeffects. Interviewees also cited limited incentives for To understand current challenges, the research looked atproviders to electronically exchange information outside the history of the EHR. Prior to meaningful use, manyof their existing closed systems, and a lack of incentives EHRs were designed primarily to create the clinical notefor vendors selling EHR systems to facilitate the exchange as a way to ensure that providers were paid appropriatelyof information with other systems. Asked to provide their by insurance companies. Peter Basch, MD, medicalvision for EHRs over the next five years and beyond, they director of e-Health for MedStar Health, indicated thatpredicted that the next generation of EHRs will offer: most providers who made a successful business case for EHR deployment tended to focus on downsizing staff,◾◾ Further integration with mobile technologies; eliminating or reducing transcriptions, and “upcoding”◾◾ Greater affordability and personalization for to maximize payments. With the focus on coding, providers; EHRs tended to pay for themselves fairly quickly, but excessive documentation was needed to justify the code◾◾ More accessibility and interoperability with other level billed. In a May 2011 article in The New England systems; and Journal of Medicine, Basch and co-authors described◾◾ Greater emphasis on patient-centeredness to how the focus on extensive documentation of patients’ encourage patient engagement in care decisions and histories and physical examinations to justify coding and communication with providers. satisfy auditors had the effect of diverting EHR vendors from focusing on enhancements to improve quality andThe experts differed in their opinions about whether the efficiency of care. Rather than developing elements togovernment should continue to take a leading role in improve workflow design or clinical decision support,influencing the marketplace for these technologies. vendors’ time, attention, and creativity were focused on automating documentation methods.All of these findings are discussed in more detail below. Project Methodology The goal of this project was to examine the past, current, and future development of EHRs through interviews with a diverse set of experts in health care, health IT, and technology. To identify experts for interviews, the researchers requested referrals and suggestions from internal subject matter experts at the California HealthCare Foundation and Booz Allen Hamilton. Using a formal interview guide, the project team sought input from experts on three overarching subjects: (1) the history and development of EHRs; (2) the influence of the Meaningful Use Incentive Program on the current EHR environment; and (3) visions and expectations for the next-generation EHR. Two members of the project team conducted each interview, completing a total of 14 interviews. The project team reviewed the information gathered, outlined the themes that emerged from the interviews, and organized the themes for publication. The team also conducted secondary research to quantify some statements provided by the interviewees. Develop Conduct Identify Conduct Identify Develop Interview Secondary Interviewees Interviews Themes Issue Brief Guide Research2 | CaliFornia HealtHCare Foundation
  3. 3. Many experts view EHRs’ initial focus on documentation Obstacles to the Evolution of EHRsand billing as the primary contributor in delaying EHR Interviewees cited several contributing factors to EHRs’optimization. Ian Morrison, PhD, founding partner of slow evolution:Strategic Health Perspectives, has worked with EHRs for • Initial Focus on Coding, Billing, andmore than 30 years and has monitored the system’s slow Documentation. Vendors had few incentives to focus on enabling EHRs to improve the qualityevolution. “It’s taken a long time to get not particularly and efficiency of care.far,” Morrison said. At their origin, EHRs were static, • Complexity of Health Care. It is challenging forpassive recipients of information, and even today, many EHRs to facilitate clinical decisionmaking whileEHRs are unable to provide real-time feedback to remaining user-friendly.providers and offer only limited data-gathering options. • Limited Focus on Information Exchange. VendorsUntil recently, most EHR systems closely resembled have few incentives to move past closed systems.personal computers prior to the popularization of the • Fee-for-Service Payment Structures. EHRs operateInternet; providers could organize and store information within the confines of the current system.on their own systems, but the data could not be shared. • Prohibitive Costs. EHR implementation is financially out of reach for some providers.“From a value perspective,” said Charles Kennedy, MD,CEO of aligned care solutions for Aetna, “you weregetting an electronic filing cabinet.” lucrative for vendors, which can charge customers forKennedy noted that the intricacies of health care additional services each time they wish to connect withdecisions have made effective EHR design challenging. another system or partner.“The complexity of physician decisionmaking within a10-minute visit is almost unimaginable. One inherent Without efforts from health industry leadership to changechallenge in EHR design is engineering data and decision incentives within the market, vendors will have littlesupport that can allow for this level of complexity, yet motivation to evolve. Even for providers with the fundsbe user friendly,” he said. John Glaser, PhD, CEO of the to pay for interoperability, there is a law of diminishingHealth Services Business Unit for Siemens, compared it to returns. Patients typically move in limited geographichiding the complexity of an automobile’s inner workings areas, and hospitals and provider groups channelfrom the driver; an effective next-generation EHR would interoperability toward high-volume relationships. Forallow the user to determine “what’s wrong with Mrs. example, a provider group will gain a larger return onSmith” without requiring the user to read through 200 investment by having connectivity with a local hospitalnotes. “That’s really, really hard to do,” Glaser said. where it frequently refers patients, rather than with a competing provider group or hospital in another town.A further problem is that many EHRs are not designedfor health information exchange. Several interviewees Fee-for-service payment — which is deeply entrenched innoted that, although meaningful use timelines will require the health care system — is another constraining factorgreater interoperability, the majority of EHR systems in the evolution of EHRs. The fee-for-service cultureoperate on closed networks that do not easily connect or — in which providers receive additional payments forcommunicate with other systems. Making connections additional services — is changing very slowly. Codingbetween providers’ EHR systems can be expensive, and structures and patient visit volume still determinesuch connections occur on a one-to-one basis. Due to payment; therefore, providers are incentivized to providethis fragmented approach, closed systems have become more expensive or more frequent care. What’s Ahead for EHRs: Experts Weigh In | 3
  4. 4. Finally, the cost of EHR adoption is too high for some description of its many capabilities; but once the systemproviders. The business case has been difficult to make was installed, the staff realized that even apparentlyfor small practices that tend to operate on slim margins. straightforward tasks were beyond their abilities. “TheIn addition to the direct cost, EHR adoption requires steps they had to go through to run reports were soradical change to the practice environment; initially slows complex that they just couldn’t do it,” Moore said.down established care and administrative processes; andprovides only modest financial benefits. Further, small The Office of the National Coordinator for Healthprovider offices — which serve a vast majority of US Information Technology (ONC) has recognized this gappatients — have little funding or information technology and is working with the Agency for Healthcare Researchstaff to assist them in implementation. In great part, these and Quality and the National Institute of Standards andare the central challenges that the federal meaningful use Technology to develop guidelines for technical evaluation,program was designed to address. testing, and validation of usability.2Concerns and Unintended Consequences Costs. For some providers, the cost of implementingof Meaningful Use an EHR system is prohibitive, even with meaningfulMost interviewed experts agreed that meaningful use use incentive payments. For an average five-physicianincentives have succeeded in creating the first “tipping practice, implementation can cost as much as $162,000,point” for EHR deployment. Providers are now less likely with up to $85,500 in maintenance expenses during theto wonder why they should implement an EHR within first year. Additionally, end users — physicians, othertheir practices and are more likely to consider when clinical staff, and non-clinical staff — need an averageand how they will adopt the technology. “Meaningful of 134 hours of training per person to effectively use ause has provided a guiding force for small and start-up typical record system in clinical encounters.3vendors” in building their products, said Indu Subaiya,MD, MBA, co-founder of Health 2.0. Vendors are now Innovation. Meaningful use may have had theincluding capabilities and functionalities that they might unintended effect of slowing innovation, accordingnot have prioritized without the influence of meaningful to some interviewees. When the Health Informationuse incentives, including considerations for patient- Technology Policy Council (HITPC) defined thecenteredness. components necessary for an EHR system to be meaningful-use certified, it diverted limited financial andHowever, some interviewees had concerns regarding personnel resources that might otherwise have been usedseveral aspects of the incentive program, including the for innovative leaps forward. Developers initially focusedfollowing: solely on the stage 1 components; they are now planning for stages 2 and 3, which are still in draft form. LeavittUsability. The HITECH Act established the criteria characterized such vendor response as an unfortunate,necessary to designate EHR technology as certified to but common, “checklist” mentality. “When people aresupport the achievement of meaningful use stage 1, paid by the government to do something specific, thenbut these criteria do not include any requirements for you’ve taken away the incentive for them to do somethingusability. L. Gordon Moore, MD, director of clinical more,” said Leavitt.transformation for Treo Solutions and president of IdealMedical Practices, described a community health center Patient-centeredness. Some components of meaningfulthat selected an EHR system based on the vendor’s use call for patient-centered capabilities, such as the stage4 | CaliFornia HealtHCare Foundation
  5. 5. 1 requirement to provide patients with an electronic which can result in limited exchange. This is a businesscopy of their health information, discharge instructions, decision to maximize investments with systems that willor clinical summaries upon request. Stage 1 also requires yield the greatest return, but some experts stated thatproviders to give patients health information or literature providers should not have to choose between capabilitiesas part of their visit. “We’re now seeing more patient and interoperability. Although proposed language forengagement than ever before,” Subaiya said, noting that stages 2 and 3 of meaningful use includes a greaterthe meaningful use requirement for after-visit summaries emphasis on interoperability, some interviewees pointedfor example, has already increased patient involvement to the limited requirements for interoperability underbeyond what was typical two years ago (prior to stage stage 1 as a missed opportunity and contributor to1 implementation). Some of the experts suggested an industry standard that prioritizes capabilities overthat more aspects of stage 1 should have been patient- interoperability.centered, and that patients should play a bigger role inconversations concerning the components of meaningful Poised for Innovationuse stages 2 and 3. Current EHR systems are built around Despite a history of slow evolution, EHRs are poisedpractices or hospitals, not patients. As a result patient for significant change over the next decade due toinformation is scattered across the health care system, developments in the policy, regulatory, and technologythereby inhibiting a holistic view of the patient’s health. environments.Interoperability. Many of the interviewees cited The Patient Protection and Affordable Care Act (ACA),interoperability as a chief concern. Beyond e-prescribing passed in 2010, signaled a shift away from fee-for-servicerequirements, stage 1 meaningful use requires providers reimbursement toward payment models that rewardto be able to share key clinical information among quality of care, rather than volume alone. Several expertsappropriate providers. However, there are requirements stated that payment and care delivery reform will have afor sharing clinical information outside the providers’ revolutionary effect on the health care system. “I franklyown health system. Specifically, stage 1 requires the think that curing cancer would have less of an impactability to “perform a test of health information exchange on the US health care system than payment reform will(HIE),” and stage 2 proposes to eliminate the HIE test have,” Siemens’ Glaser said. In recent decades, payers“in favor of objectives that use HIE.” 4 (See Appendix B.) and employers have spearheaded efforts to controlAs a result, vendors have little incentive to facilitate health spending by promoting integrated care deliveryinformation sharing outside of closed systems, and and rewarding performance. Momentum has beenmost EHR-enabled health systems operate in silos. building for collaborative care models, such as patient-Technological concerns also remain an issue, particularly centered medical homes (PCMHs) and accountable carein the standards arena. For example, EHR vendors and organizations (ACOs), which leverage technology totheir customers may not adhere to existing standards improve quality and control costs.on transmission and receipt of patient data, and codedvocabularies are often implemented differently in different The ACA significantly increased attention to ACOssystems. through the Medicare Shared Savings Program (MSSP), designed to financially reward provider groups whoWhen providers choose to invest in interoperability collectively bear risk for the full continuum of carewith other providers and systems, they typically elect to for Medicare beneficiaries and demonstrate savingsconnect with those whom they interact most frequently, by providing high-quality and well-coordinated care. What’s Ahead for EHRs: Experts Weigh In | 5
  6. 6. Notably, the most-heavily weighted quality criterion The interviewees noted that EHR systems will need tofor the MSSP is the ACO’s use of an EHR system.5 more effectively support population health managementACOs are commonly expected to require EHRs and and patient engagement in virtually integrated systemsHIE capabilities, as well as additional tools to manage of care. In addition to established providers and insurers,population risk, including analytics and business a new generation of doctors is creating a demand forintelligence, revenue cycle management, personal health effective, innovative health IT. Morrison observed thatrecords, and member engagement tools. many newly graduating physicians “won’t go anywhere without an electronic [health record] system,” andPatient-centered medical homes will require technological that both patients and providers seek more convenienttools that exceed the capabilities of today’s EHRs in interactions outside of office visits. The evolution oforder to facilitate technology-enabled care coordination companies such as athenahealth, American Well, andacross distributed and diverse care teams. For example, RelayHealth is representative of the growing need forthe Special Care Clinic (SCC) in Atlantic City, New more patient-provider communication.7 In the future,Jersey, a recognized innovator in primary care and chronic these sites may look more like social networks. In oneillness management, uses non-clinical health coaches example, Hello Health has taken social networking andto work with patients — in person, by phone, and by EHR practice management capabilities and combinedemail — to help them manage their health. Although them into one Web-based system, enabling better patient-SCC uses an EHR system as a foundational technology, provider communication.the center’s leadership has been vocal about the shortfallsof currently available systems and has identified specific Many providers also use mainstream social media toolsopportunities where EHRs must evolve or converge with to communicate with their patients. Nearly 1,200 USother technologies to address the needs of medical home hospitals use some form of social media to interact withpractices.6 their patients, including Facebook, LinkedIn, Twitter, and Foursquare.8 Social networking allows patients toPrivate insurers are also prioritizing use of health IT as contact their providers via a medium that is familiar tothe traditional business of health insurance erodes and them. Patients can also create circles of health care thatas firms diversify into services and care delivery. Health include their providers and loved ones, and they canplans have developed significant capabilities in health communicate via a multitude of communications tools,management based largely on claims data. The potential including email, text messaging, and voicemail. As thesevalue of clinical data for integrated health analytics, types of communications become more mainstream, andas well as more direct intervention in support of care as a younger generation of doctors becomes integratedmanagement, has fueled investment in EHRs, HIE, and into the workforce, patients will likely come to expect topatient communication technologies. Ted Eytan, MD, communicate with their providers in these ways.a director at The Permanente Federation, explained thatintegrated health systems encompassing both insurance Finally, new technologies to improve patient care are moreplans and provider groups, such as Kaiser Permanente, promising when combined with EHRs. Matthew Holt,Geisinger, and Health Partners, use EHRs to improve co-founder of Health 2.0, described a growing numbercare and reduce costs by viewing patients and their care of tracking tools and sensors that can be used to morein a more comprehensive manner. “Models like ours have continuously monitor clinical and behavioral indicators,pushed the development of EHRs to be more human- such as blood pressure or eating habits. Another trackercentered,” Eytan said. combines an inhaler with a Global Positioning System6 | CaliFornia HealtHCare Foundation
  7. 7. (GPS) for asthmatics to identify regions more likely to provide core services and support extensively networkedinduce an attack. When integrated into EHRs, the data data from across the health system, as well as facilitatecollected by such devices can provide physicians with a substitutable applications, similar to iPhone “apps.” 10more integrated view of their patients’ health, particularlyfor those with chronic conditions that require close To realize the full potential of EHRs, however, themonitoring. next generation of systems must allow for data to be accessible and usable by appropriate parties. The mostEventually, a wave of genomic data will add even greater realistic scenario for the near future seems to be local ordepth and diversity to the information providers and regional systems uniting providers that have significantlypatients can use to manage health in a more continuous overlapping patient communities. Meaningful use stagesand personalized way. These trends collectively suggest 2 and 3 may help bring this scenario closer to reality.that EHRs, and the larger IT environment, are on theverge of greater change and improvement. In the distant future, health records could become completely interoperable and independent of vendor,The Next Generation of EHRs provider, and format. Stakeholders across the healthThe promise of EHRs was further defined by the experts’ care community derive greater benefits when healthvisions for the future. The interviewees said that they information flows freely, the experts noted. In aexpect EHRs to play a larger role over time in providing September 2009 paper titled “Toward Health Informationhigh-quality, low-cost care. Liquidity: Realization of Better, More Efficient Care from the Free Flow of Health Information,” Booz Allen’sFinancial incentives for EHR adoption and resulting Kristine Martin Anderson and co-authors pointed tocompetition among vendors have already begun to drive increasing evidence that free-flowing patient data fromdown the cost of EHRs. Overarching trends toward more pharmacies, laboratories, and medical imaging improvesloosely coupled technical architectures and distributed health care access, safety, convenience, efficiency,data sources will favor cost-constrained adopters, such as and outcomes. The paper asserted that free-flowingsmall provider groups, which may be able to use pared- information, when combined with a concerted focus ondown interfaces for simple data needs on inexpensive and the patient, can be particularly effective in opening theeasy-to-use devices such as iPads. door to innovation.Providers are already using mobile health applications for Many of the experts interviewed said they believefunctions including educating patients, aiding in diagnosis the future of health care should be rooted in patient-and treatment, and collecting data remotely. More than centeredness, and that EHR systems could go far10,000 mobile health applications are already available, beyond the mandates of meaningful use in promotingwith some 6,000 on iTunes, and the data from these patient-centeredness. From a patient perspective, theapplications can be integrated into EHRs.9 Researchers at desired health care practice or system would promoteChildren’s Hospital Boston and Harvard Medical School proactive care and accountability, offer convenient access,are taking these trends a step further by investigating and help patients deal with their conditions and treatmentcreating prototype approaches to achieve an “iPhone-like” options, assist them in making good choices, offer thehealth IT platform model, through a grant provided by best of science, and treat them with dignity and respect.ONC’s Strategic Health IT Advanced Research Projects Many of these attributes can be realized through a highly(SHARP) program. The platform architecture will functioning EHR system that accommodates patient What’s Ahead for EHRs: Experts Weigh In | 7
  8. 8. access and participation in an innovative, forward- engaging more in their own health care and holdingthinking way. providers accountable for quality.EHRs can foster proactive care by enabling patient Kaiser Permanente offers a patient portal intended to notand provider to create a shared agenda. For example, only provide patients with access to their EHRs, but alsoEHRs can create alerts for screenings and chronic care to remind them of upcoming care needs. Upon signingmanagement that can be discussed while the patient is in to the portal, patients receive alerts for information,in the physician’s office for a different reason. From a check-ups, updates on lab results, and simple stepspractical standpoint, Basch said, providers should pay and recommendations for health improvement. Kaiserattention to the patient’s chief complaint, but avoid Permanente’s success demonstrates that future EHRs musthaving it become a “chief distraction” that gets in the way go far beyond their roots in documentation and billing.of addressing other care opportunities. Scheduling further The next generation of systems will not only advancecare should be possible with a few clicks. in the capture and integration of clinical data, but also represent a key point of engagement for providers orOutside of office visits, patients should be able to securely health coaches to help “activate” patients.communicate with their providers directly via email,social networking, or other online tool that augments Such initiatives build on market and technology trendsthe EHR capabilities without creating additional data already evident: the increasing use of communicationsilos or isolated communication channels. Enabling tools, the proliferation of mobile devices, advances inpatients to communicate electronically with health care sensor technologies, and a growing wave of online healthproviders and gain access to medical records may also tools. All of these increase patients’ abilities to be theirimprove physician-patient relationships and help motivate own best advocates and play a role in their own care.patients to play an active role in managing their chronicconditions. Initiatives aimed at patient activation are Next Steps: Regulations vs. Free Marketemerging from diverse sources. Most of the experts agreed that meaningful use regulations have contributed to the increase in widespreadThe Department of Veterans Affairs (VA) is focusing on a EHR adoption, but they disagreed on which forces shouldpatient-centered model in its Virtual Lifetime Electronic drive continued EHR development. Some promotedRecord initiative, said Peter L. Levin, PhD, senior advisor further government involvement and intervention, whileto the secretary and chief technology officer for the VA. others believed EHRs would advance more quickly if“By applying some relatively ordinary tools and methods market forces were left to drive innovation.from computer science, IT, and clinical practice,” Levinsaid, “we learned that there were tremendously impactful A Regulated Market Viewthings we could do quickly” to improve EHRs and Several interviewees suggested that meaningful usepatient access to them. (Patients may opt out if they are should be expanded to include more robust requirementsuncomfortable with electronic records.) A cornerstone for data-sharing and interoperability. Large and smallof that effort has been the Blue Button project, which vendors could be required to share information in aenables veterans, service members, and Medicare meaningful way, such as developing notification systemsbeneficiaries to download their personal health record as to alert relevant providers that a patient within a givena readable file. Being patient-centered is critical, Levin community has been admitted to the emergency room.said, because he predicts a “tectonic shift” toward patients Morrison took this idea a step further by suggesting that8 | CaliFornia HealtHCare Foundation
  9. 9. the federal government should “make it illegal for systems The federal government also fosters HIE throughto operate in fiefdoms” — perhaps monitoring the field the State Health Information Exchange Cooperativein the same way that antitrust regulations are enforced. Agreement Program (State HIE) and the BeaconMoore noted that data-sharing requirements should also Community Program. Through the State HIE Program,be accompanied by legislated firewalls to assure patients ONC has granted 56 awards totaling $548 million tothat their personal data would not be accessible through promote innovative approaches to the secure exchange ofany data-mining efforts by the Internal Revenue Service health information within and across states and to ensureand the Department of Homeland Security. that providers and hospitals meet national standards and meaningful use requirements.14 Launched in 2010, theSome interviewees suggested that vendors be required, Beacon Community Cooperative Agreement Programunder meaningful use or other means, to make data has provided a total of $220 million to 17 selectedinteroperable with other systems. While vendors asserted communities throughout the US. The objective is tothat this would be extremely difficult, some experts said focus on specific and measurable improvement goalsvendors may be overstating the challenge. Leavitt noted in the three vital areas for health systems improvementsimilarities to the cellular phone industry’s objections (quality, cost-efficiency, and population health) and toto recent Federal Communications Commission (FCC) demonstrate the ability of health IT to transform localrules to allow customers to keep their phone numbers health care systems.15when switching service providers.11 Several intervieweessuggested that meaningful use certification could require In addition to funding innovation and informationthat data be made interoperable so that providers are not exchange efforts, the federal government can spur thebound to one vendor or system indefinitely (or incur creation of a robust IT infrastructure that is standardizedsignificant costs to change systems). This requirement and interoperable. Given the extensive federal investmentcould increase vendors’ focus on customer service and to promote the adoption of individual EHR systems,usability because of the new risk that providers may take many interviewees indicated that the government hastheir business elsewhere. an equally important role in laying the groundwork for a nationwide network of exchange and interoperability.Given the current financial climate and the capital The federal government has taken steps in this directionrisk associated with innovation, some suggested the through the Nationwide Health Information Network,federal government should assume a leading role in and future efforts can build on this work. As Levinspurring innovation in health IT. One such example is explained, “the greatest power for change lies in the abilityONC’s SHARP program, mentioned above, which is to share information with anyone who needs it, regardlessdesigned to support innovative research that addresses of their EHR system.”well-documented problems impeding the adoption ofhealth IT.12 ONC also leads the Investing in Innovations Interviewees generally agreed that physicians and patients(i2) Initiative, a program that leverages competition should have greater input into future EHR-relatedand awards to spur health IT innovations.13 While these legislation and regulations. Before the governmentefforts are still in their nascent stages, they demonstrate endorses a vision for the next-generation EHR, consumersthe federal government’s growing role in incentivizing and end-users could be included on a design team toinnovation. determine what the future should look like. In this way, the federal government and EHR vendors could follow the lead of consumer product companies, which What’s Ahead for EHRs: Experts Weigh In | 9
  10. 10. have become increasingly advanced in their abilities Once the issue of federal government certification is into listen and respond to consumers’ wants and needs. the past, vendors may take the opportunity to capitalizeInterviewees also suggested that evaluation of any on simpler, less expensive EHR systems that meet thegovernment-sponsored adoption of EHRs or similar needs of small practices. For example, some individualhealth IT initiatives should include patient perceptions providers or small practices may be able to improveand feedback as a primary source of input through workflow, coordinate care, and collect patient datasurveys, focus groups, or other means. Considerations of through limited-capacity EHR systems that would notthe patient experience with EHRs should include whether necessarily have met the meaningful use certificationcare is timely, needs are met, and communication with criteria. Post-meaningful use, vendors will likely need tophysicians is satisfactory. be more innovative in creating diverse products with a range of capabilities to meet the needs of various practicesA Free Market View and health systems. Simple systems could be enabled toAlternatively, some experts suggested the federal connect with larger systems’ networks for data analyticsgovernment should forgo future involvement in advancing and population-level reporting. These shared capabilitiesEHRs because of their perception that regulations can could allow providers of all sizes to reap the benefits ofhamper innovation. Assuming ACA legislation remains in health IT by allowing them to purchase and integrate theplace, market-driven innovation in health IT and EHRs systems with the functionality most relevant for them.is likely to occur as providers seek tools for improvingquality and reducing costs through care coordination. There are indications that the private sector is alreadyVendors will need to go beyond certification to prove advancing EHR optimization and HIE. A group of seventheir worth to providers, and providers will assume a states and 11 health IT vendors recently collaborated ongreater role in sharing information about their experiences a set of technical specifications to standardize health datausing various systems. sharing among providers, health information exchanges, and other parties. The specifications leverage existingInterviewees explained that existing user forums interoperability standards from ONC and are the result ofand satisfaction surveys for EHRs have limitations, a workgroup launched in 2011 by the New York eHealthand providers may seek avenues for real-time or Collaborative. The specifications enable two importantanonymous feedback. This approach may mimic the HIE capabilities: (1) patient record look-up, which allowssocial networking-inspired rating systems and sites for clinicians to query an HIE for relevant data on a specificother products and services, such as Zagat ratings and patient, and (2) point-to-point data sharing, which allowsYelp. In a Yelp-type service for EHRs, providers could encrypted health information to be transmitted point-evaluate, document, and categorize their experiences to-point over the Internet.16 This effort is indicative ofwith various systems and the finances required to adopt a growing market force that may spur innovation andand implement the system. This increased transparency advancement in EHRs and health IT — with or withoutwould create more confident purchasers and raise the federal government intervention.expectations for EHR systems’ quality, functionality,usability, and customer service.10 | CaliFornia HealtHCare Foundation
  11. 11. Conclusion AuthorsDespite decades of slow evolution and limited Timathie Leslie, Vice Presidentimplementation, meaningful use has created a tipping Megan Doscher, Lead Associatepoint for EHR adoption. Although experts debate Brynnan Toner, Associate Booz Allen Hamiltonwhether meaningful use has hampered innovation,most agree that EHRs are poised for significantchange in the coming decade due to recent changes in About the F o u n d At i o ntechnology and the health system, provided that EHRs’ The California HealthCare Foundation works as a catalyst toevolution continues beyond the lifespan of meaningful fulfill the promise of better health care for all Californians.use incentives. The experts agreed that EHRs must We support ideas and innovations that improve quality,become more user-friendly, accessible for patients, and increase efficiency, and lower the costs of care. For moreinteroperable to enable information sharing across the information, visit us online at www.chcf.org.health care community.The next generation of EHRs will also represent akey point of engagement for new types of data andcommunications as patients and providers interact inways that are more continuous, virtual, and personalized.Patients will expect to be able to schedule appointmentsonline and will become frustrated with providers thatrequire them to repeatedly fill out medical historyforms. They will seek integrated systems that can assuretheir information will be appropriately shared duringemergency situations. Providers and hospitals that donot share data or allow patients to readily access theirinformation will face a loss of market share or riskdecreased payments.Insurers, for their part, will likely require providers withintheir networks to implement EHRs as a standard practiceof good medicine. In many cases, insurers may becomeeither an information service provider or partner inleveraging EHR technology to manage risk. Some expertssuggested insurers may even provide incentives, such as areduced copayment, for patients to choose providers withpayer-approved EHR systems.Regardless of government intervention, more effective useof EHRs has the potential to transform every aspect ofhealth care in the US, and most experts believe the futureis promising. What’s Ahead for EHRs: Experts Weigh In | 11
  12. 12. Appendix A: Expert InterviewsKristine Martin Anderson L. Gordon Moore, MD Senior Vice President Director of Clinical Transformation, Treo Solutions Booz Allen Hamilton President, Ideal Medical PracticesTim Andrews Ian Morrison, PhD Vice President Founding Partner Booz Allen Hamilton Strategic Health PerspectivesPeter Basch, MD Jeremy Nobel, MD Medical Director, Ambulatory EHR and Health IT Policy Medical Director MedStar Health Northeast Business Group on HealthTed Eytan, MD Indu Subaiya, MD, MBA Director, The Permanente Federation, LLC Co-Founder Kaiser Permanente Health 2.0John Glaser, PhD CEO, Health Services Business Unit SiemensYael Harris, PhD Director of the Office of Health IT & Quality Health Resources and Services AdministrationMatthew Holt Co-Founder Health 2.0Charles Kennedy, MD CEO of Aligned Care Solutions AetnaMark Leavitt, MD, PhD Retired Chair Certification Commission for Healthcare Information TechnologyPeter L. Levin, PhD Senior Advisor to the Secretary and Chief Technology Officer Department of Veterans Affairs12 | CaliFornia HealtHCare Foundation
  13. 13. Appendix B: Summary of Stage 2 and Stage 3 of Meaningful UseAccording to CMS, the optional objectives under the EHR incentive programstage 1 will be required under stage 2, and thresholds and exclusions will bere-evaluated for all measures.17, 18 Final stage 2 requirements are anticipated inmid-2012 and implementation in 2013.The stage 2 recommendations are based on the five domains, or priorities,created in stage 1, including: (1) improve quality, safety, efficiency, and reducehealth disparities; (2) engage patients and families in their care; (3) improve carecoordination; (4) improve population and public health; and (5) ensure adequateprivacy and security protections for personal health information.19The same process for developing stage 1 and 2 will be used to develop stage 3criteria, including heavy reliance on public comments.20 The stage 3 requirementsare expected to focus on enabling specialists to potentially qualify for meaningfuluse incentive payments, and on ensuring that meaningful use measurements alignwith other federal programs, such as the Medicare Shared Savings Program and theNational Strategy for Quality Improvement in Health Care. Stage 3 implementationis expected in 2015. What’s Ahead for EHRs: Experts Weigh In | 13
  14. 14. endnotes 11. Federal Communications Commission. “FCC Consumer Facts.” Keeping Your Telephone Number When You 1. Hsiao, CJ, E. Hing, T.C. Socey, B. Cai. Electronic health Change Your Service Provider. September 2011. record systems and intent to apply for meaningful use www.fcc.gov. incentives among office-based physician practices: United States, 2001–2011. NCHS data brief, no 79. Hyattsville, 12. “Get the Facts about Strategic Health IT Advanced MD: National Center for Health Statistics. 2011. Research Projects (SHARP) Program.” Office of the National Coordinator for Health Information Technology. 2. Lewis, Nicole. “NIST: Make EHRs More User-Friendly.” 27 April 2011. www.healthit.hhs.gov. InformationWeek Healthcare. 1 November 2011. www.informationweek.com. 13. “HHS and The Office of the National Coordinator for Health Information Technology introduce new Investing 3. Fleming, Neil S., et al. “The Financial And Nonfinancial in Innovations (i2) Initiative.” US Department of Health Costs Of Implementing Electronic Health Records In and Human Services. 8 June 2011. www.hhs.gov. Primary Care Practices.” Health Affairs (2011): 481-489. 14. “Get the Facts about Federal Health Information 4. “Health Information Technology Policy Committee Exchange Program.” 8 March 2011. Office of the Recommendations for Stage 2 Meaningful Use.” 7 July National Coordinator for Health Information Technology. 2011. Office of the National Coordinator for Health November 2011. www.healthit.hhs.gov. Information Technology. November 2011. www.healthit.hhs.gov. 15. “Beacon Community Program: Improving Health Information Technology.” 19 May 2011. Office of the 5. “Medicare Shared Savings Program Final Rule.” 20 October National Coordinator for Health Information Technology. 2011. Department of Health and Human Services, Centers November 2011. www.healthit.hhs.gov. for Medicare and Medicaid Services. October 2011. www.federalregister.gov. 16. McGee, Marianne. “Progress On Health Data Exchange Specs.” InformationWeek. 8 November 2011. 6. Fernandopulle R., N. Patel. “How the Electronic Health Record Did Not Measure Up to the Demands of Our 17. “Electronic Health Record Incentive Program; Final Rule.” Medical Home Practice.” Health Affairs (2010); 29(4): 28 July 2010. Federal Register. November 2011. 622-628. edocket.access.gpo.gov/2010/pdf/2010-17207.pdf. 7. Cueva, Amy. “Healthcare Information and Management 18. Drazen, Erica. “Update On Stage 2: Current Direction Systems Society.” Social Media and Patient-Centric And Timing Of Meaningful Use Requirements.” Design: Facilitating Provider/Patient Relationships. Computer Sciences Corporation (2011). (2011). 19. “Health Information Technology Policy Committee 8. Bennet, Ed. Hospital Social Network Data & Charts. 8 Recommendations for Stage 2 Meaningful Use.” 7 July June 2011. Found in Cache. September 2011. 2011. Office of the National Coordinator for Health www.ebennett.org. Information Technology. November 2011. www.healthit.hhs.gov. 9. Horowitz, Brian T. “Mobile, EHRs to Fuel 24 Percent Health Care IT Growth by 2014: Report.” eWeek. 20. Manos, Diana. “Federal panel begins work on Stage 3 25 May 2011. meaningful use.” Healthcare IT News. 10 November 2011.10. “HMS Researchers Lead $15 Million Federal Research Grant to Support Advancement of Health Information Technology.” 8 April 2010. Harvard Medical School, Office of Communications and External Relations. November 2011. www.hms.harvard.edu.14 | CaliFornia HealtHCare Foundation